Mind the Gaps

[dropcap]A[/dropcap]my Killelea of the National Alliance of State and Territorial AIDS Directors (NASTAD) sees healthcare coverage gaps everywhere, and as director of NASTAD’s new Health Systems Integration (HSI) team, she plans to close some of them.

Some of those gaps speak to the success, not failure, of the Affordable Care Act (ACA). They include low-income people left out of health coverage in states without expanded Medicaid under ACA and the lack of federal and state coverage for people with the hepatitis C virus (HCV). Killelea tells A&U that there are now more people who qualify for private insurance and Medicaid, but helping them take advantage of the coverage they’re entitled to—especially testing and treatment for the hepatitis C virus—is another matter.

“Many more people are covered with insurance now that weren’t before the ACA, and for people who had viral hepatitis or HIV, (the ACA) has been a lifeline. But with all those people newly covered, health insurance literacy becomes an issue. It’s one thing to have an insurance card and it’s another to know how to use it.”

Teaching the newly insured about the benefits of insurance and actually using it, instead of going to the emergency room—NASTAD says a large number of newly-insured are still doing this even though they don’t need to—is just one area NASTAD’s HSI team will be focusing on.

There’s also the matter of medications, especially the newer life-saving antivirals for hepatitis. Private insurers are putting them on high specialty tiers with high co-pays that keep them out of reach of most people who need them. Killelea says HSI can put pressure on regulators to stop this kind of price gouging and on insurers to bring at least some of their newer hepatitis meds into a lower pricing tier.

“We have federal HIV treatment guidelines, but none for hepatitis C, and there are arbitrary restrictions. If you’re co-infected with HIV, there are government programs that fill the gap, but for mono-infected people [with HCV], there’s nothing right now.”

It’s not just hepatitis C patients that will benefit from the efforts of HSI. The HSI team is focusing on closing gaps by focusing on four areas:

1. Health insurance coverage and access. By supporting the AIDS Drug Assistant Program (ADAP) and other HIV and viral hepatitis programs, HSI aims to get more people with these diseases covered and into treatment. The team is searching for and supporting plans that include HIV and viral hepatitis medications, services, and providers. And HSI is identifying payment and delivery system reform models that include community-based public health services.

2. Provider sustainability. The HSI team works with state health departments to pursue contracts and other partnerships with public and private payers, and go after new streams of revenue to sustain services.

3. Insurance claims data. HSI works with state HIV programs to leverage private insurance and Medicaid claims data to improve the ability of states to measure HIV and viral hepatitis outcomes and progress.

4. PrEP financing. While PrEP is a promising tool in ending the HIV epidemic, it is a no-man’s land of federal funding. CDC and HERSA funding only covers patients with a diagnosis of HIV. But because PrEP is used to prevent infection in HIV-negative people, federal funding does not cover it.

HSI is a new initiative, just announced in October, and the details on how exactly those efficiencies are going to be built and how “systems and payers are effective partners in ending the HIV and hepatitis C epidemics,” as their press materials say, are still emerging.

Some of NASTAD’s proposals for streamlining hepatitis C and HIV care and prevention are detailed in its recent white paper, “Modernizing Public Health to Meet the Needs of People Who Use Drugs.” The paper suggests creative payment and delivery reforms, as well as ways of pushing broader health systems to be more accountable for meeting the health needs of people who use drugs.

The real success of NASTAD’s Health Systems Integration effort will be determined by how many people with HCV and HIV or are at risk for either will be able to access the care they need, affordably. To that end, Kilelea believes that within two years public and private payers will take on more responsibility for ending hepatitis C and HIV, and Medicaid will be playing a larger role in these services. She also believes that more states will expand Medicaid as part of the Affordable Care Act.

And, she says, testing for hepatitis and HIV will be routine in the next two years with the efforts of her HSI team. “When people go to primary care, they should routinely get tested for these viruses.”

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